ZOLOFRA INSURANCE AGENCY

Ready to protect you today for what matters tomorrow.

Homeowners Form

*First & Last Name *Date of Birth (include month, day and year) *Phone number *Occupation *Email address *Address (#, street, unit #, city, state, zip and county) *Have you filed for bankruptcy within the last 7 years? Who is your current homeowners insurance company? What is your policy expiration date? What is your ANNUAL homeowners premium? For discount purposes, who is your current auto carrier and what is the current policy #? *Purchase Price of home *Mortgage Amount *Make this insurance payment part of your mortgage payment? *How many mortgages do you have on this home? *When is your closing date or when did you move in? *What is the distance to the nearest fire hydrant? *What is the distance to the nearest fire station? *Identify the type of features and systems you have in your home:
Local Alarm (Fire and Burglar)
Central Fire
Central Burglar
Sprinklers
Gated Community
Temperature Monitoring
Back-up Generator
None of the above
*Age of Home: *Home type: # of Families *How many occupants? *Construction Type: *What type of siding is on your home? (i.e. vinyl, wood, stucco, etc.) *Number of stories (not including basement) *Style of house (ranch, colonial, split, etc) *Overall square footage of living space. *How many bedrooms? *How many full bathrooms? *How many half bathrooms? *Do you have any specialty rooms (study, exercise) if so, please identify type. *Do you also have any of the following? (check all that apply)
Decks
Porches
Patios
Custom kitchens/baths
Cathedral ceilings
Fireplaces
Attached Garage
Detached Garage
Central Air
Jacuzzis
None of the above
*Your home's inside walls are composed of? (i.e. sheetrock, plaster, block) *What type of roof & roof style does your home have? *Do you have any custom windows? If so, advise how many and type. *Basement
None, on a slab
Finished
Unfinished
Partially finished
Partial basement
*Type of heat:
Above ground oil tank
Below ground oil tank
Electric
Gas
Wood stove
*What year was the wiring updated/renovated? *What year was the plumbing updated/renovated? *What year was the heating updated/renovated? *What is the age of the roof? *Regarding your exterior, please check all that apply:
Above ground pool
Inground pool
Pool has a slide
Pool has a diving board
Pool is fenced
Trampoline(s) on premises
If required, I am willing to remove the trampoline(s) within 30 days
None of the above
*How many acres is your property? Do you have any other structures on your property not mentioned here? Please describe.
*Have you had any losses in the past 3 years? If yes to losses, please advise on type of loss, date of loss and payments:
If you have pets, please advise on type of pet and breed. Please advise on any bite history
Would you like to have any jewelry, furs, fine arts or silverware insured also? If so, please advise on type and value below.
Do you have any full-time domestic workers, nannies or caretakers? If so please advise below.
If you live in an association, do you pay a maintenance fee? If so, please quote increased Loss Assessment Coverage. Are you interested in obtaining quotes on higher limits of liability? If yes to higher limits, please list the locations, # of vehicles and underlying limits:
List the names, dates of birth, driver license #'s and the underlying carriers for each youthful driver.
Do you also own any of the following? (check all that apply)
Minibikes
Mopeds
Motorcycles
Motorhomes
Aircraft
Snowmobiles
Golfcarts
None of the above
Regarding any owned watercraft, please identify the type, size of vessel and horsepower.
Did we miss anything? Include additional comments here.

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Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

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